ADDicted

It is no secret that the ADD diagnosis is sometimes made haphazardly,
that doctors or psychologists, succumbing to the needs of weary
parents, occasionally recommend Ritalin after asking only a few cursory
questions. But when the Shipleys took Brent to see psychologist Betty
Hart in February of his kindergarten year, the examination was anything
but casual. Hart took a detailed family history and inquired into the
minutiae of Brent's school and home life. She had Brent's kindergarten
teacher fill out a questionnaire.

And Hart observed Brent herself. She put Brent alone in a playroom
stocked with toys and told him to "entertain" himself. Through a
one-way mirror, she and the Shipleys watched as he quickly emptied the
toys from the shelves and then abandoned them in small piles on the
floor. "He couldn't complete a single task," Cindy says. "And that's
one of the main things that characterizes ADD."

After Hart's evaluation, just as Brent was about to turn 6, he began
to take 5 milligrams of Ritalin three times a day: in the morning, at
noon, and in the afternoon when he arrived home from school. A year
later, he was taking 10 milligrams three times a day, which is a fairly
typical dose for kids.

Ritalin allowed Brent to settle down and concentrate almost
immediately, although he did experience some common side effects. He
lost his appetite, so much so that he hardly ever ate lunch. And the
effects of the 10-milligram dose peaked early and dramatically. A
half-hour after ingesting the medication, Brent would become lethargic,
going, as his mother describes it, "from hyper to staring at the
TV."

In the 4th grade, Brent switched to a time-release tablet with an
all-day effect. Consequently, Cindy says, things are much improved.
Brent's appetite is still best in the morning, but he now eats lunch
and dinner, as well. And the mood swings aren't so dramatic. Brent is
now on a more even keel.

For the majority of doctors who prescribe Ritalin, ADD is as much
a medical condition as diabetes or hemophilia.

For the great majority of doctors who prescribe Ritalin, attention
deficit disorder is as much a medical condition as diabetes or
hemophilia. It doesn't matter to them that researchers have been unable
to find a definitive medical cause. Most would probably agree that
Brent's symptoms--his pronounced inattentiveness, impulsiveness, and
hyperactivity--point to a classic case of ADD.

"It's an inherited condition, a designer disorder," says Peoria
psychologist Eric Ward, who has perhaps diagnosed more cases of ADD
than any other local clinician. "Those who say that ADD doesn't exist
or that its diagnosis is hopelessly subjective are usually those who
don't get in the trenches and do a lot of this work. People come into
this office with this list of complaints so strikingly similar that
when I tell them what else is involved in the cluster of symptoms they
have this kind of 'aha' experience. 'You really know,' they say.
'You've been to our house.' But, of course, I haven't. And what makes
it even more remarkable is that many have other children with whom
they've used the same parenting and discipline methods, and yet the
children demonstrate behavior that's not at all similar."

In the 1980s, Ward trained with Russell Barkley, a professor of
psychiatry and neurology at the University of Massachusetts Medical
Center whose 1990 book, Attention Deficit Hyperactivity Disorders: A
Handbook for Diagnosing and Treatment, is still considered the last
word among those working in the field. From Barkley, Ward learned a
simple but critical lesson: You can only diagnose ADD when you can make
a clear distinction between a conduct problem and the attention deficit
disorder. As Ward explains it, many children chronically and willfully
misbehave on account of inadequate parenting and poor discipline. What
distinguishes the ADD kid, on the other hand, is an absence of willful,
intentional misbehavior. According to this line of thinking, kids like
Brent really don't know why they do certain things. Much of the time,
they are acting on sheer impulse.

"Parents with ADD children," Ward explains, "will say, 'So and so
doesn't obey me because he's in a dream world and distractible.' It's
not just a case of the child being defiant and angry."

ADD, Ward adds, tends to surface very early in a child's life,
before parenting styles can have much influence. Parents are often
aware of an ADD-type disorder by their child's second birthday. Some
mothers know, or claim to know, while the child is still in the
womb.

The key to an accurate diagnosis is the "cross situational" nature
of the disorder.

But diagnosis, Ward insists, must never rely solely on parental
testimony. The key to an accurate diagnosis is the "cross situational"
nature of the disorder: ADD symptoms must appear in a variety of
settings--both at home and in school, for instance. "If it's truly a
chemical, biological disorder," Ward says, "then it's got to go with
you from place to place." A difficult child who becomes calmer and more
attentive after a few months in a disciplined classroom setting
probably does not have ADD, Ward says. "The parents will say, 'We had a
heck of a time in September and early October, but by the end of
October everything was a lot better.' "

Although Ward has few doubts about his ability to diagnose and treat
ADD, others are much less sanguine. In fact, they are deeply disturbed
by the exuberant confidence of people like Boston psychiatrist Edward
Hallowell, who, in the first sentence of his best-selling 1994 book,
Driven to Distraction, declares, "Once you catch on to what this
syndrome is all about, you'll see it everywhere."

Hallowell may see it everywhere, but other doctors and psychologists
looking at the very same kids have a hard time spotting it at all. One
of them is pediatrician Sharon Collins of Cedar Rapids, Iowa, where,
according to a recent study, some 8 percent of children in elementary
and middle school take Ritalin.

"I'm frustrated; I'm crying out," Collins says. "When our children
are born, we're so pleased to have this wonderful child--a child who no
one else is like. Then they enter preschool, and they're all supposed
to be the same, and so we label those who are not, ADD."

Collins says she is under great pressure to prescribe Ritalin. And
in fact she occasionally does. "I have people who come to me on
Ritalin, and I can't always change their minds," she says. "So I
prescribe it, though it's not in my heart. And I've had people for whom
I won't prescribe it leave my practice."

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